The anxious patient who cannot sit still may not be anxious

Akathisia gets missed because it presents as the thing everyone expects in a psychiatric ward: restlessness, distress, an inability to settle. Treated as anxiety or as worsening illness, it earns the patient more antipsychotic, which makes it worse — and akathisia carries a real association with suicidality, so this is not a cosmetic error.

Two questions separate them. Ask where the feeling is: anxiety is usually described in the chest or the stomach and comes with worry about something, while akathisia is described in the legs, as a compulsion to move rather than a fear. Then ask whether moving helps. A patient with akathisia will say that pacing relieves it and sitting still makes it unbearable; an anxious patient will not usually say that movement fixes anything.

Then look. Ask the patient to sit for a minute with their feet flat on the floor and watch the legs — rocking, marching in place, crossing and uncrossing. The timing matters too: akathisia clusters in the first weeks after a start or a dose increase, which is exactly when a depot injection has just been given.

• Ask where the restlessness is felt — legs points to akathisia, chest or stomach to anxiety.
• Ask whether moving relieves it; relief on movement is close to diagnostic of akathisia.
• Observe the patient seated for a full minute rather than relying on the interview.
• Date the symptom against the last dose change or injection, not against the illness.
• If it is akathisia, review the dose before adding anything — do not treat it as breakthrough agitation.

Why it matters

Mistaking akathisia for anxiety leads to more of the drug causing it, in a side effect that carries its own risk.

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